bisphosphonate – related osteonecrois · synthetic analogs of naturally occurring pyrophosphate -...
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Bisphosphonate–Related Osteonecrosis:
Where are we today and what the future holds?
Babak Bina DMDDirector of General Practice Residency
Lutheran Medical CenterBrooklyn
Bisphosphonate-Related Osteonecrosis
Bisphosphonates - Synthetic analogs of naturally occurring pyrophosphate- Potent inhibitors of bone resorption
- Internalized by osteoclast, decrease their ability to resorb bone and their life expectancy.
- Cause osteoclast apoptosis
- Incorporates into hydroxyapatite and changes bone micro architecture
Bisphosphonate-Related Osteonecrosis
R1 (Hydroxyl Group) :Increase the affinityR2 cause the anti-resorption
1st Generation (Non- Nitrogen Containing) : R2 group is non-nitrogen
Etidronate (Didronel) – CH3Clodronate (Benofos)- Cl
Bisphosphonate-Related Osteonecrosis2nd Generation: R2 group contains
nitrogen in form of a primary amino group
- Alderonate (Fosamax)- Pamidronate (Aredia)- 10-1000 more potent than the 1st
generations
Bisphosphonate-Related Osteonecrosis3rd Generations: R2 group contains
nitrogen but within a heterocyclic group
- Risedronate (Actonel)- Ibandronate (Boniva)- Zoledronic Acid (Zometa)- 10,000- 100,000 more potent than 1st
generation
Bisphosphonate-Related Osteonecrosis
All the cases that have been reported so far were associated with the nitrogen- containing bisphosphonates (Zometa, Aredia, Boniva, Actonel, Fosamax)
There has not been any reported cases of BRONJ associated with non-nitrogen containing BPs (Didronel, Skelid and Bonefos)
Bisphosphonate-Related Osteonecrosis
WHY?1) Mevalonate pathway VS synthesis of ATP analogues ----
Potency
2) Effect of nitrogen containing on vascularization
Bisphosphonate-Related Osteonecrosis TIMELINE
September 2003
Dr.Robert Marx reported avascular necrosis of the jaws in 36 patients taking Aredia or Zometa
50% of patients had Multiple Myeloma
December 2003 :
Dr. Marx and Dr.Ruggiero: Presentation to Novartis board. San Antonio, TX
May 2004
Dr. Ruggiero and colleagues reported 63 patients with BRON over 3 years span (2001-2003)
28 patients had Multiple Myeloma
Bisphosphonate-Related Osteonecrosis TIMELINE
September 2004
Novartis, manufacturer of Aredia and Zometa, notified healthcare professionals about addition of osteonecrosis of the jaws to warning labels
2005, warning label was added to oral BP
June 2006
ADA released expert panel recommendation for management of patients on Oral Bisphosphonate therapy
September 2006
American Association of Oral and Maxillofacial Surgeons released expert panel recommendation
Bisphosphonate-Related Osteonecrosis TERMINOLOGY
BRONJ
Bisphosphonate-Related Osteonecrosis of the Jaw/AAOMS
BON
Bisphosphonate-associated osteonecrosis/ADA
Osteochemonecrosis ????
BRON
Bisphosphonate-Related osteonecrosis
Bisphosphonate-Related Osteonecrosis CAUSES
Why?1. Defect in wound healing and jawbone
remodelingOsteoclast inhibition:
impaired osteoclast function interferes with normal bone turnover and resorption causing dense, poorly formed brittle bone
Bisphosphonate-Related Osteonecrosis CAUSES
Why?2. Compromised blood flow and lack of
oxygenation:- Inhibition of endothelial cell function- Inhibition of blood vessels sprouting- Cells demonstrate decrease proliferation and Capillary tube formation
- Anti-angiogenic properties due to decreased levels of VEGF, a potent angiogenic factor
Bisphosphonate-Related Osteonecrosis CAUSES
Why?3 Combination of 1 and 2:
Decreased blood flow and poor oxygenation in combination with poorly formed bone
Hypothetical mechanism of osteonecrosis induced by potent nitrogen-containing bisphosphonates. Through inhibition of osteoclast function (a) and angiogenesis (b) the regenerative capacity of the bone is impaired. After local trauma the non-healing wound can develop into osteonecrosis and is prone to surinfection by commensal flora (c) leading to osteomyelitis. T. Van den Wyngaert1,2,*, M. T. Huizing1
and J. B. Vermorken1
Annals of Oncology 2006 17(8):1197-1204;
Bisphosphonate-Related Osteonecrosis CAUSES
Why?4. Hypocalcemia coupled with elevated
PTH serum level Ardine et al: Ann Oncol 2006
Bisphosphonate-Related Osteonecrosis
IV Bisphosphonate:- Used in patients with breast, prostate, lung
and other cancers with bone metastasis- Management of lytic lesions such as Multiple
Myeloma- Osteoporosis? NEJM (Zometa 2mg/6months
or 4mg/year)- Giant Cell Tumor ???
StagingStage 1
Characterized by exposed bone that is asymptomatic with no evidence significant soft tissue infection
Courtesy of Dr. Ruggiero
Bisphosphonate-Related Osteonecrosis
IV Bisphosphonate:Impacts the quality of life in patients when
cancer involves the skeletal system:- Prevents and/or reduces hypercalcemia- Stabilizes bony pathology- Prevents fractures
Bisphosphonate-Related OsteonecrosisIV Bisphosphonate:1. pamidronate (Aredia): 1991 Novartis
administered over a 2-24 hour period every 3-4 weeks/90mg
2. zoledronic acid (Zometa): 2001 Novartis
administered over a 15 minutes period at 4mg dosage
3. clodronate (Bonefos): Schering AG
used mainly in Canada both oral/IV
Bisphosphonate-Related Osteonecrosis
More than 2.8 million patients have been treated with IV BP
Incidence:- February 2005, Novartis was aware of 875 cases- Fall of 2005, increased to 2,227 cases- April 2006, AAOMS did an internet survey of 1,235 members and reported 4,737 cases
Bisphosphonate-Related OsteonecrosisDurie et al (NEJM 2005) :1,203 patients with breast cancer andMM revealed 12.8%
Depending on studies incidence ranges from 0.8-12 % and is rising
Bisphosphonate-Related Osteonecrosis
• Oral Bisphosphonate:• Over 190 millions prescriptions • Used to treat osteoporosis and
osteopenia• Used in patients with Paget’s Disease
and Osteogenisis Imperfecta
Osteoporosis vs Osteopenia
Osteoporosis is a disease that breaks down the tissue in our bones, making them fragile and more likely to break
Osteopenia is not a disease, but a term that describes low bone density
Both can lead to painful fractures
Bisphosphonate-Related Osteonecrosis
DEXA(Dual Energy X-ray Absorptiometry):• Use to measure bone density• Lower spine and hips• Use to diagnose osteoprosis and
osteopenia
Bisphosphonate-Related Osteonecrosis
T Score:T more than –1 is normal-2.5< T < -1.0 OsteopeniaT less than –2.5 is osteoprosis
Fosamax: Osteopenia 35mg/dayFosamax: Osteoprosis 70mg/day
Bisphosphonate-Related OsteonecrosisOral Bisphosphonates
Actonel (risedronate) Procter & GambleBoniva (ibandronate) Roche laboratoryFosamax (alendronate) Merck & CoFosamax Plus D Merck & CoSkelid (tiludronate) Sanofil PharmDidronel (etidronate) Procter & GambleBonefos (clodronate) Schering AG
Bisphosphonate-Related Osteonecrosis
March 2006 (ADA ):- Fosomax (1997) 170 cases- Actonel (1998) 20 cases- Boniva (2005) 1 case
Translates into 0.7 cases per 100,000 people
Australian and Israeli reports (0.01-0.04%)with extraction (0.09-0.34%)
Bisphosphonate-Related OsteonecrosisAccording to AAOMS a case is considered to be
BRONJ when all of the following characteristics are present:
1. Current or previous treatment with BP2. Exposed, necrotic bone in the maxillofacial
region that has persisted for more than eight weeks.
3. No history of radiation therapy to the jaw
Bisphosphonate-Related Osteonecrosis
Diagnosis;- Panorex and PA are poor radiographic
screenings How to Diagnose:
Clinical Presentation
Bisphosphonate-Related Osteonecrosis
- Symptoms: pain, soft tissue swelling and infection, loosening of teeth, drainage and exposed bone.
- Majority occur after dental treatment- Rarely spontaneous- May present with in weeks or months after
dental treatment
Bisphosphonate-Related OsteonecrosisRisk factors for development of BRONJ:1. Drug- related risk factors
a. Potency: Zometa (100,000)> Boniva (10,000) > Actonel (10,000) > Fosamax (1,000) > Aredia (100) > Skelid (10) >Didronel (1)b. Duration and Dosage of therapy
Bisphosphonate-Related Osteonecrosis
2. Local Risk Factors:a. Dentoalveolar surgery: Surgery increases risk by 7-9 timesb. Local Anatomy: Man/Max (2:1), more in the area of tori, mylohyoid ridge, bony exostoses
Bisphosphonate-Related OsteonecrosisRisk factors con’t3. Demographic, Systemic and other factors- Age: with each decade 9% increase - Race: Caucasians- Cancer Diagnosis: MM>Breast>others- Osteoprosis, Diabetes, Smoking, Alcohol,
corticosteroid, Chemotherapeutic Drugs, Poor oral hygiene
Bisphosphonate-Related Osteonecrosis
Treatment Strategies:A. Patients about to initiate IV
bisphosphonte- Caries control- Extraction of Non-restorable and/or
teeth with poor prognosis (14-21 days prior to IV)
- Emphasis on hygiene/routine exam
Bisphosphonate-Related OsteonecrosisB. Asymptomatic Patients on IV:- Emphasis of oral hygiene/Check-up- Avoid procedures that cause direct osseous
injury- Non-restorable teeth may be treated by
removal of the crown and endo treatment of the remaining root
- Implants should be avoided in patients that had 4-12 times dose/year ???
Bisphosphonate-Related Osteonecrosis
C. Asymptomatic Patients on oral BPs:1. Patients taking oral BPs less than
three years and no risk factors:- No alteration- Add risk in your informed consent for
surgeries
CONSENT FOR ORAL SURGERY IN PATIENTS WHO HAVE RECEIVED CONSENT FOR ORAL SURGERY IN PATIENTS WHO HAVE RECEIVED ORAL BISPHOSPHONATE DRUGSORAL BISPHOSPHONATE DRUGS
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PatientPatient’’s Names Name DateDate
Please initial each paragraph after reading. If you have any Please initial each paragraph after reading. If you have any questions, please ask your doctor BEFORE initialing.questions, please ask your doctor BEFORE initialing.___ 1.___ 1. You have been treated with oral You have been treated with oral BisphosphonateBisphosphonate drugs, and drugs, and you should know that there is a risk of future severe complicatiyou should know that there is a risk of future severe complications that might ons that might happen with dental treatment. There is a small but real risk. happen with dental treatment. There is a small but real risk. Jaw bones Jaw bones usually heal themselves very well and maintain their normal healusually heal themselves very well and maintain their normal health. In some th. In some patients, patients, BisphosphonateBisphosphonate drugs seem to affect the ability of jaw bones to drugs seem to affect the ability of jaw bones to break down or remodel themselves, and this interferes with the jbreak down or remodel themselves, and this interferes with the jawaw’’s ability s ability to heal itself. This risk is increased after surgery, especiallto heal itself. This risk is increased after surgery, especially from extractions, y from extractions, gum surgery, implant placement or other gum surgery, implant placement or other ““invasiveinvasive”” procedures that might procedures that might cause even mild trauma to bone. Necrosis (dying cells) or cause even mild trauma to bone. Necrosis (dying cells) or OsteonecrosisOsteonecrosis (dying bone cells) may result, and an infection may occur in the(dying bone cells) may result, and an infection may occur in the soft tissue soft tissue and/or inside and/or inside thth bone. This is a longbone. This is a long--term process that destroys the jawbone term process that destroys the jawbone that is often very hard or even impossible to get rid of.that is often very hard or even impossible to get rid of.
___ 2.___ 2. Your medical/dental history is Your medical/dental history is veryvery important. We must important. We must know the medications and drugs that you have received or taken bknow the medications and drugs that you have received or taken before, efore, andand are receiving or taking now. A correct medical history, includiare receiving or taking now. A correct medical history, including names of ng names of physicians is important.physicians is important.
___ 3.___ 3. The decision to stop oral The decision to stop oral BisphosphonateBisphosphonate drug therapy before drug therapy before dental treatment should be made by you in talking with your medidental treatment should be made by you in talking with your medical doctor.cal doctor.
___ 4___ 4 If a complication occurs, antibiotic therapy may be used to If a complication occurs, antibiotic therapy may be used to help control infection. For some patients, such therapy may cauhelp control infection. For some patients, such therapy may cause allergic se allergic responses or have undesirable side effects such as stomach discoresponses or have undesirable side effects such as stomach discomfort, mfort, diarrhea, swelling of the colon, etc. diarrhea, swelling of the colon, etc.
___ 5.___ 5. If If osteonecrosisosteonecrosis should occur, treatment may be long and should occur, treatment may be long and difficult. You might need ongoing intensive therapy that could difficult. You might need ongoing intensive therapy that could include include hospitalization, taking antibiotics for a long time, and removalhospitalization, taking antibiotics for a long time, and removal of dead bone. of dead bone. Reconstructive surgery may be needed, including bone grafting, mReconstructive surgery may be needed, including bone grafting, metal plates etal plates and screws, and/or skin flaps and grafts.and screws, and/or skin flaps and grafts.
___ 6.___ 6. Even if there are no immediate complications from the Even if there are no immediate complications from the proposed dental treatment, the area is always subject to breakdoproposed dental treatment, the area is always subject to breakdown by itself wn by itself at any time and infection due to the unstable condition of the bat any time and infection due to the unstable condition of the bone. Even the one. Even the smallest trauma from a toothbrush, chewing hard food, or denturesmallest trauma from a toothbrush, chewing hard food, or denture sores may sores may set off a complication.set off a complication.
CONSENT FOR ORAL SURGERY TREATMENT IN PATIENTS WHO HAVE RECEIVEDCONSENT FOR ORAL SURGERY TREATMENT IN PATIENTS WHO HAVE RECEIVED ORAL ORAL BISPHOSPHONATE DRUGSBISPHOSPHONATE DRUGS
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____ 7.____ 7. We may need to see you on a longWe may need to see you on a long--term basis after your surgery to check your condition. It is veterm basis after your surgery to check your condition. It is very ry important that you keep all of your scheduled appointments with important that you keep all of your scheduled appointments with us. Regular and frequent dental checkus. Regular and frequent dental check--ups with your ups with your dentist are important to try to prevent breakdown in your oral hdentist are important to try to prevent breakdown in your oral health.ealth.
____ 8.____ 8. I have read the information above and understand the possible riI have read the information above and understand the possible risks of having my planned treatment. sks of having my planned treatment. I understand and agree to the following treatment plan:I understand and agree to the following treatment plan:
__________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________
____ 9.____ 9. I understand the importance of my health history and I have giveI understand the importance of my health history and I have given you all information. I understand n you all information. I understand that if I donthat if I don’’t give you true health and complete information, it may be harmft give you true health and complete information, it may be harmful to my care and lead to unwanted ul to my care and lead to unwanted complications.complications.
____ 10.____ 10. I realize that even though the doctors will take all precautionsI realize that even though the doctors will take all precautions to avoid complications; the doctor canto avoid complications; the doctor can’’t t guarantee the result of the proposed treatment.guarantee the result of the proposed treatment.
CONSENTCONSENTI certify that I speak, read and write English and have read andI certify that I speak, read and write English and have read and fully understand this consent for surgery and have fully understand this consent for surgery and have had my questions answered. All of the blanks were filled in befhad my questions answered. All of the blanks were filled in before I initialed or signed the form.ore I initialed or signed the form.
PatientPatient’’s (or Legal Guardians (or Legal Guardian’’s) Signatures) Signature DateDate
DoctorDoctor’’s Signatures Signature DateDate
WitnessWitness’’ SignatureSignature DateDate
Bisphosphonate-Related Osteonecrosis2. Patients taking oral BPs less than three
years and also taking corticosteroids:contact the provider to stop BPs for three months prior to treatment and re-start after osseous healing
3. Patients taking oral Bps for more than 3 years with/without steroids: Same as above
Dear Dr. ______________________Dear Dr. ______________________ Date ____________Date ____________
Re: _________________Re: _________________
I am currently seeing your patient, __________________. Your paI am currently seeing your patient, __________________. Your patient informs me that she/he has been taking tient informs me that she/he has been taking an intravenous or oral an intravenous or oral bisphosphonatebisphosphonate ((FosamaxFosamax, , ActonelActonel, , BonivaBoniva, , DidronelDidronel, , SkelidSkelid). As you know, a number of ). As you know, a number of patients have developed patients have developed osteonecrosisosteonecrosis of the jaws (ONJ) after taking of the jaws (ONJ) after taking bisphosphonatesbisphosphonates, particularly IV , particularly IV bisphosphonatesbisphosphonates..
The American Association of Oral and Maxillofacial Surgeons has The American Association of Oral and Maxillofacial Surgeons has recently issued a recently issued a ““Position PaperPosition Paper”” on on ““BisphosphonateBisphosphonate--Related Related OsteonecrosisOsteonecrosis of the Jawsof the Jaws””. While oral . While oral bisphosphonatesbisphosphonates are associated with only a are associated with only a small number of small number of osteonecrosisosteonecrosis cases at this time, it appears that the risk of developing cases at this time, it appears that the risk of developing BisphosphonateBisphosphonate--Related Related OsteonecrosisOsteonecrosis of the Jaws (BRON) associated with oral of the Jaws (BRON) associated with oral bisphosphonatesbisphosphonates may be increased when duration of may be increased when duration of therapy exceeds three years, and/or when oral therapy exceeds three years, and/or when oral bisphosphonatesbisphosphonates are given concomitantly with longare given concomitantly with long--term term corticosteroids or chemotherapy, the patient has diabetes, smokecorticosteroids or chemotherapy, the patient has diabetes, smokes, uses excessive alcohol, or has poor oral s, uses excessive alcohol, or has poor oral hygiene. Your patient meets one of these criteria.hygiene. Your patient meets one of these criteria.
For patients who have been on oral For patients who have been on oral bisphosphonatesbisphosphonates more that 3 years, or have taken oral more that 3 years, or have taken oral bisphosphonatesbisphosphonates and and have one of the additional risk factors listed above, the AAOMS have one of the additional risk factors listed above, the AAOMS Position Paper recommends the following for Position Paper recommends the following for patient management prior to any elective patient management prior to any elective dentoalveolardentoalveolar surgery:surgery:
““ ……the prescribing provider should be contacted to consider discontthe prescribing provider should be contacted to consider discontinuation of the oral inuation of the oral bisphosphonatebisphosphonate (drug holiday) for at least three months prior to oral surgery(drug holiday) for at least three months prior to oral surgery, , if systemic conditions permit. if systemic conditions permit. The The bisphosphonatebisphosphonate should not be restarted until osseous healing has occurred (appshould not be restarted until osseous healing has occurred (approximately three more months).roximately three more months).””
Please advise our office by return fax (____________)if you wouPlease advise our office by return fax (____________)if you would:ld:
CHECK ONECHECK ONE
recommend a drug holiday as described aboverecommend a drug holiday as described above ____________
not recommend a drug holiday as discussed above not recommend a drug holiday as discussed above ____________
Signature__________________Signature______________________________________________
Once we have your recommendation, we will contact your patient wOnce we have your recommendation, we will contact your patient with your recommendation and schedule our ith your recommendation and schedule our surgery in compliance with it. Thank you for your help with thisurgery in compliance with it. Thank you for your help with this patient. Working together, we can provide good s patient. Working together, we can provide good care for your patient.care for your patient.
Cordially,Cordially,
Bisphosphonate-Related Osteonecrosis
• June, 2006, ADA, Expert panel recommendation:Not allergic to penicillin
Amoxicillin: 500mg / q8h/ 14 days
Metronidazole: 250mg/ q8h/ 14 days- Allergic to penicillin- Clindamycin 300mg/ q8h/ 14 days- Azithromycin 250mg/ q24h/ 10 days- Start antibiotic 1-2 days prior the procedure- Chlorhexidine/ 2x/ day/ two months post surgery
Bisphosphonate-Related Osteonecrosis
Patients with established BRONJ:Stage 1:Exposed/necrotic bone in patients who are asymptomatic and have no evidence of infection
Treatment: Use of oral antimicrobial rinses, such as chlorhexidine 0.12%
Staging
Stage 1
Characterized by exposed bone that is asymptomatic with no evidence significant soft tissue infection
Courtesy of Dr. Sal Ruggiero
Bisohosphonate-Related Osteonecrosis
Stage 2:Exposed/necrotic bone in patients with pain and
clinical evidence of infection:Treatment: oral antimicrobial rinses in
combination of antibiotic therapyi.e Penicillin group, quinolones, metranidazloe,
clindamycin, doxycycline, erythromycin Sometimes combination/ IV antibiotics
Staging
Stage 2
Exposed bone associated with pain, soft tissue and/or bone infection
Courtesy of Dr. Sal Ruggiero
Bisphosphonate-Related Osteonecrosis
Stage 3:Exposed/necrotic bone in patients with pain,
infection, and one or more of the following: pathological fractures, extra-oral fistulas, or osteolysis extending to the inferior border
Treatment:Surgical debridement/resectionAntibiotic/oral microbial rinsesRemoval of mobile segments and extraction of
symptomatic teeth within exposed boneDiscontinuation of BP (oral 6-12 months)
StagingStage 3
Pathologic fracture
Exposed bone associated with soft tissue infection that is not manageable with antibiotics due to the volume of necrotic bone.
Courtesy of Dr. Sal Ruggiero
Bisphosphonate-Related Osteonecrosis
CTX (C-terminal telopeptide):- Fragments of type I collagen- Is a bone marker that is sensitive to
bone turn-over and is used for assessment of bone resorption
Bisphosphonate-Related OsteonecrosisCTX ( Carboxy-Terminal Telopeptide):- Blood test/morning/fasting- Has been used by Rheumatologists- CA (San Juan Capistrano)Quest Diagnostic 1800-642-4657- Only for Oral-Bisphosphonte- No value for IV-Bisphosphonate- Not necessary in patients with less than 3
years on BPs
Bisphosphonate-Related Osteonecrosis
- The lower the CTX the less chances of osteoporosis
Does this mean the higher chances of osteonecrosis ???
- Normal Range F= 60-600 (pre-menopause)M= 60-800
Bisphosphonate-Related OsteonecrosisBRONJ RiskHigh Risk:
CTX less or equal 100 pg/mlModerate Risk:
CTX between 101-150pg/mlLow Risk:
CTX equal or more than 151CTX value will increase with
discontinuation of Oral Bisphosphonates
Bisphosphonate-Related Osteonecrosis
Suggestion:- Stop bisphosphonate in patients with
CTX below 151 for 3-4months- Another blood test if value above 150
continue with the procedure- Restart Oral BPs 3 months after
procedure
Bisphosphonate-Related Osteonecrosis
No ConsernAB?
add to consent
Less than 3 years
CTX ????less than 151
stop BPS for 3-4 monthsNew CTX/AB? add to consent
less than 3 years+
CorticostersoidsMore than 3 Years
Oral Form
Not started yetExtract Hopeless teeth
wait 14-21 days recalls
Currently on IV BPsNo SurgeriesRCT on roots
Hygiene
IV Form
Bisphosphonate
Bisphosphonate-Related Osteonecrosis- Why CTX (not NTx,alkaline phosphatase,
osteocalcin) - Why 151 ? (Lab is not aware of any
correlation)- Bone et al: The effects of prolonged use of
10mg of Aredia are sustained even 5 years after discontinuation.
- Oral Bisphosphonate use for more than three years will have effect on bone morphology for years.
Bisphosphonate-Related Osteonecrosis
Alternatives to current oral BPs (Are they Practical?):
1. Exercise and calcium2. Alternating oral BPs 6 months on/off3. Reloxifene (Evista): designer estrogen
1/10,000 will develop blood clot4. Rh PTH 1-34 (forteo): increase bone
formation 100-300% within 3 months Peaking at 9 months. What if Ardine is right?
Bisphosphonate – Related Osteonecrosis
- Osteoprotic fractures in 1995:Half million fractures800,000 emergency visits2.6 million office visit180,000 individuals in nursing home
- 2006: 1.5 million fractures per year at cost of 14 Billion (Life time cost of a hip fracture is $81,300)
- 300,000 hip 700,000 vertebral250,000 wrist 300,000 other
- 10 years: estimated 5.2 million fractures a year in U.S
Bisphosphonate-Related Osteonecrosis
- 44 million American have osteoprosis:- 1 in 2 men and 1 in 4 female with
history of osteoprosis will have fractures.
- 24 % of hip fracture patients will die within a year and another 20 % end up in nursing homes.
Fosamax:- Decreases the risk of hip fracture by
33%- Decreases the hip fracture by 100,000
and death associated with fractures by 25,000 a year.
Bisphosphonate-Related OsteonecrosisCase 1:
65 year male referred to O.S. at VA Northport for evaluation, prior to radiation to the jaw
PMH: History of prostate cancerMeds: Treatment with Aredia and Zometa
- Patient has not worn his partial denture for more than a year
- No recent history of dental treatment
Case and Slides Courtesy of Dr.David Salehani
Bisphosphonate-Related OsteonecrosisNuclear Bone Scan:- 3 stage scan, the tracer will be injected in the
arm- First scan right after the injection, 2nd scan 3-
4 hours after- Christmas tree picture- The area that absorbs the most gamma
radiation appears dark or “Hot Spots”- These areas indicate a fracture, an infection
or metastasis (usually more than one area of hot spot is an indication of metastasis)
Bisphosphonate-Related Osteonecrosis
Case 2:58 YO Middle Eastern female presentedfor implant placement to private practice in January 2006
PMH: Non- significantMeds: Fosamax for two years
Case 3:78 YO Hispanic female
PMH: HBPMeds: Fosamax for past 10 yearsCC: Pain on lower left to hot and biting
Bisphosphonate-Related Osteonecrosis
Bisphosphonate-Related OsteonecrosisMost common commonly prescribed medication
on patient>50 (Dose Dependent)1. Lipitor 10 mg2. Norvasc 5mg3. Fosamax 70mg4. Plavix 75mg10. Norvasc 10mg11. Lipitor 20 mg
Bisphosphonate-Related Osteonecrosis
Special thanks to Dr. Salvatore Ruggiero and Dr. David Salehani